Abstracts
Objective
(1) To evaluate whether the Nine Items Questionnaire (WOQ-9) for the detection of wearing-off (WO) in Parkinson Disease (PD), by means of its screening ability, is a helpful tool to assist neurologists in diagnosing WO; (2) To determine the sensitivity and the specificity of a free Brazilian Portuguese translation of WOQ-9.
Method
A sample obtained by convenience included 60 patients. The WOQ-9 was answered by the patients themselves before their routine consultations. The detection of the WO by the WOQ-9 was compared with the neurologist assessment. Statistical significance was 5%.
Results
The WOQ-9 showed sensitivity of 100%, specificity of 10.3%, positive and negative predictive values of 54.4% and 100% respectively. The identification of WO by the WOQ-9 was congruent in 54.5% of cases with neurological evaluation.
Conclusion
The WOQ-9 is a convenient screening tool to aid physicians to detect WO in PD patients, and it is a quick and easy self-administered questionnaire.
Parkinson's disease; levodopa; wearing-off; questionnaire
Objetivo
(1) Verificar se o Questionário de Nove Itens (WOQ-9) para detectar wearing-off (WO) na doença de Parkinson (DP), pela sua capacidade de triagem, seria útil aos neurologistas na identificação de WO; (2) determinar a sensibilidade e especificidade da versão livre em Português Brasileiro do WOQ-9.
Método
Ao todo 60 indivíduos com DP compuseram uma amostra obtida por conveniência. Os próprios pacientes responderam ao WOQ-9 antes de suas consultas rotineiras. A detecção de WO pelo WOQ-9 foi comparada com a avaliação neurológica. A significância estatística foi 5%.
Resultados
O WOQ-9 apresentou sensibilidade de 100%, especificidade de 10,3%, valores preditivos positivo e negativo de 54,4% e 100% respectivamente. A identificação de WO pelo WOQ-9 foi congruente em 54,5% dos casos com a avaliação neurológica.
Conclusão
O WOQ-9 é um método de rastreamento útil para identificar WO em pacientes com DP, e é um questionário de autoavaliação cuja aplicação é fácil e rápida.
doença de Parkinson; levodopa; wearing-off ; questionários
The treatment of Parkinson's disease (PD) remains a major challenge spite of the
increasing therapeutic arsenal in recent decades and progressing knowledge of its
pathophysiology. Levodopa (LD) remains the most effective and widely prescribed drug in
the symptomatic treatment of PD11 . Olanow CW. Levodopa dopamine replacement strategies
inParkinson's disease: future directions. Mov Disord. 2008;23 Suppl
3:S613-22. http://dx.doi.org/10.1002/mds.22061
https://doi.org/10.1002/mds.22061...
.
Currently it is acknowledged that up to 50% of patients have motor fluctuations after
two years of the introduction of LD or another dopaminergic agonist (DA)22 . Stocchi F, Jenner P, Obeso JA. When do levodopa motor fluctuations
first appear in Parkinson’s disease? Eur Neurol. 2010;63(5):257-66.
http://dx.doi.org/10.1159/000300647
https://doi.org/10.1159/000300647...
,33 . Parkinson Study Group. Levodopa and the progression of
Parkinson’s disease. N Engl J Med. 2004;351:2498-508.
http://dx.doi.org/10.1056/nejmoa033447
https://doi.org/10.1056/nejmoa033447...
.
The long-term use of levodopa leads to complications directly related to the duration of
the treatment. Such complications include motor symptoms (MS) and non-motor symptoms
(NMS). The most frequent motor complications are the motor fluctuations and dyskinesias.
Wearing-off (WO) is one subtype of motor fluctuation and occurs over time, when the
effectiveness of a dose of dopaminergic agonist tends to wear off earlier than before.
For confirmation of this phenomenon, WO symptoms should improve after the intake of the
next dose of antiparkinsonian drug (AD)22 . Stocchi F, Jenner P, Obeso JA. When do levodopa motor fluctuations
first appear in Parkinson’s disease? Eur Neurol. 2010;63(5):257-66.
http://dx.doi.org/10.1159/000300647
https://doi.org/10.1159/000300647...
.
The physiopathology of WO is controversial; it could be due to the decrease of the
pre-synaptic dopamine receptors with consequent diminished storage capacity of dopamine
in the striatum, or beyond post-synaptic mechanisms as the interruption of signal
transduction for synthesis of proteins mediated by D1 and D2 receptors, or because of
dopamine depletion due to neuronal loss. However, the loss of the physiological
integrity of the outflow tracts of the basal ganglia is the fundamental prerequisite for
the emergence of WO. The reduction and later extinction of the phasic release of
dopamine by the nigrostriatal system, culminates with a tonic stimulation of
postsynaptic dopamine receptors44 . Obeso JA, Rodriguez-Oroz M, Marin C, Alonso F, Zamarbide I,
Lanciego JL et al. The origin of motor fluctuations in Parkinson’s
disease: importance of dopaminergic innervation and basal ganglia circuits.
Neurology. 2004;62(Suppl 1):S17-30.
http://dx.doi.org/10.1212/wnl.62.1_suppl_1.s17
https://doi.org/10.1212/wnl.62.1_suppl_1...
. After
the introduction of LD therapy, the improvement of PD symptoms follows two patterns
undistinguishable clinically in the initial stages of the treatment. Firstly the
improvement of the symptoms begins rapidly, lasts for an average of 4 to 5 hours after
ingestion of the medication and provides relief mainly of the MS, this is known as
“short duration pattern”55 . Nutt JG, Holford NH. The response to levodopa in
Parkinson’s disease: imposing pharmacological law and order. Ann Neurol.
1996;39(5):561-73. http://dx.doi.org/10.1002/ana.410390504
https://doi.org/10.1002/ana.410390504...
. Secondly, occurs the “long duration pattern”, when a
prolonged improvement of the symptoms after dopaminergic stimulation is observed,
generally obfuscated in the initial stages of the treatment with LD or DA, and this
effect may sustain up to fourteen days after stopping the AD55 . Nutt JG, Holford NH. The response to levodopa in
Parkinson’s disease: imposing pharmacological law and order. Ann Neurol.
1996;39(5):561-73. http://dx.doi.org/10.1002/ana.410390504
https://doi.org/10.1002/ana.410390504...
.
The early recognition of WO allows the treatment of this complication in less advanced
stages of PD, reduces the emergence of complications related to WO and may delay its
progression66 . Schapira AH, Obeso J. Timing of treatment initiation in
Parkinson’s disease: a need for reappraisal? Ann Neurol.
2006;59(3):559-62. http://dx.doi.org/10.1002/ana.20789
https://doi.org/10.1002/ana.20789...
. Strategies to
ameliorate WO includes the optimization of dopaminergic therapy and/or the early
introduction of catechol-O-methyl transferase (COMT) inhibitors in association to LD.
Studies showed that either treatment option have similar results to improve motor
fluctuation77 . Parkinson Study Group. Entacapone improves motor fluctuations in
levodopa-treated Parkinson’s disease patients. Ann Neurol.
1997;42(5):747-55. http://dx.doi.org/10.1002/ana.410420511
https://doi.org/10.1002/ana.410420511...
,88 . Nissinen H, Kuoppamäki M, Leinonen M, Schapira AH. Early
versus delayed initiation of entacapone in levodopa-treated patients with
Parkinson’s disease: a long-term, retrospective analysis. Eur J Neurol.
2009;16(12):1305-11.
http://dx.doi.org/10.1111/j.1468-1331.2009.02726.x
https://doi.org/10.1111/j.1468-1331.2009...
,99 . Larsen JP, Worm-Petersen J, Siden A, Gordin A, Reinikainen K,
Leinonen M. The tolerability and efficacy of entacapone over 3 years in patients
with Parkinson’s disease. Eur J Neurol. 2003;10(2):137-46.
http://dx.doi.org/10.1046/j.1468-1331.2003.00559.x
https://doi.org/10.1046/j.1468-1331.2003...
,1010 . Brooks DJ, Leinonen M, Kuoppamäki M, Nissinen H. Five-year
efficacy and safety of levodopa/ DDCI and entacapone in patients with
Parkinson’s disease. J Neural Transm. 2008;115(6):843-9.
http://dx.doi.org/10.1007/s00702-008-0025-8
https://doi.org/10.1007/s00702-008-0025-...
.
Many studies have verified whether questionnaires answered by patients are helpful to
enhance the detection of WO1111 . Stacy M, Bowron A, Guttman M, Hauser R, Hughes K, Larsen JP et al.
Identification of motor and nonmotor wearing-off in Parkinson’s disease:
comparison of a patient questionnaire versus a clinician assessment. Mov Disord.
2005;20(6):726-33. http://dx.doi.org/10.1002/mds.20383
https://doi.org/10.1002/mds.20383...
,1212 . Stacy M, Hauser R. Development of a patient questionnaire to
facilitate recognition of motor and non-motor wearing-off in Parkinson’s
disease. J Neural Transm. 2007;114(2):211-7.
http://dx.doi.org/10.1007/s00702-006-0554-y
https://doi.org/10.1007/s00702-006-0554-...
,1313 . Stacy M, Hauser R, Oertel W, Schapira A, Sethi K, Stocchi F et al.
End-of-dose Wearing Off in Parkinson disease: a 9-question survey assessment.
Clin Neuropharmacol. 2006;29(6):312-21.
http://dx.doi.org/10.1097/01.wnf.0000232277.68501.08
https://doi.org/10.1097/01.wnf.000023227...
,1414 . Stacy MA, Murphy JM, Greeley DR, Stewart RM, Murck H, Meng X. The
sensitivity and specificity of the 9-item Wearing-off Questionnaire.
Parkinsonism Relat Disord. 2008;14(3):205-12.
http://dx.doi.org/10.1016/j.parkreldis.2007.07.013
https://doi.org/10.1016/j.parkreldis.200...
. This study aimed to assess whether WOQ-9 is an useful tool to
assist neurologists to detect WO in clinical practice, increasing its identification.
The sensitivity and specificity of the WOQ-9 to detect WO were determined by comparing
the identification of WO by the clinical evaluation performed by neurologists. We also
analyzed which symptoms of the WOQ-9 were more frequent and disabling, and the
prevalence of other symptoms not included in the WOQ-9.
Method
This was a cross-sectional study conducted at the Movement Disorders Clinic of the Department of Neurology of the University of Sao Paulo School of Medicine during the period of May 2011 to May 2013, and it was approved by the local ethical committee.
The WOQ-9 was translated from English into Brazilian Portuguese but not formally
validated. WO was present if the patient checked at least one symptom of the Nine
Items Questionnaire for WO (WOQ-9). Moreover, it was confirmed if the
patient’s chosen symptoms improved after the intake of the next AD1313 . Stacy M, Hauser R, Oertel W, Schapira A, Sethi K, Stocchi F et al.
End-of-dose Wearing Off in Parkinson disease: a 9-question survey assessment.
Clin Neuropharmacol. 2006;29(6):312-21.
http://dx.doi.org/10.1097/01.wnf.0000232277.68501.08
https://doi.org/10.1097/01.wnf.000023227...
. The clinical assessment was the
gold standard method for diagnosing WO. Sensitivity was defined as the probability
that a PD patient, presenting WO according to clinical assessment, be sorted as
having WO by WOQ-9 and specificity was defined as the probability that a PD patient
without WO ascertain by physician would be classified as being without the condition
by the WOQ-9. The positive predictive value (PPV) and negative predictive value
(NPV) represented the likelihood of subjects with WO assessed by WOQ-9 truly
experienced WO or not, respectively, when compared with the clinical assessment.
Study population
A non-probabilistic sample was obtained by convenience. All individuals had
idiopathic PD (according to the UK Parkinson’s Disease Society Brain Bank
Clinical Diagnostic Criteria1515 . Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical
diagnosis of idiopathic Parkinson’s disease: a clinico-pathological study
of 100 cases. J Neurol Neurosurg Psychiatry. 1992;55(3):181-4.
http://dx.doi.org/10.1136/jnnp.55.3.181
https://doi.org/10.1136/jnnp.55.3.181...
) and fulfilled the following inclusion criteria: at least
30 years old, literate, duration of disease of at least 2 years, use of LD
and/or DA, Hoehn and Yahr scale score (HY) <51616 . Hoehn MM, Yahr MD. Parkinsonism: onset, progression, and
mortality. Neurology. 1967;17(5):427-42.
http://dx.doi.org/10.1212/wnl.17.5.427
https://doi.org/10.1212/wnl.17.5.427...
, and to have provided written informed consent.
Patients with cognitive impairment or severe psychiatric co-morbidity were
excluded.
Study design
Seventy-five patients were invited to participate to the study. However, while answering the questionnaire, eleven were excluded due to functional illiteracy and four because they presented cognitive impairment or severe psychiatric co-morbidity. At the conclusion of the study the final sample was composed of 60 individuals.
The patients answered to the WOQ-9 on the same day, before their routine neurological consultation. One specialist in movement disorders, named investigator, instructed the patients to mark an “x” to “yes” if they had any of the nine symptoms and "no if none of them was present. The investigator explained that if the answer was “yes” the patient had to check an “x” to “yes” or “no” if symptoms improve or not after taking the next AD, respectively. If the answer was “no” patients would not need to proceed to the second question about the corresponding symptom. These instructions were given to all patients by the investigator who had his function limited to supervise the patient’s task of filling out the questionnaire. The educational level of the patients was ascertained and scored according to the number of years studied (studied years).
After completion of WOQ-9, each individual would also read and answer two questions: – Which are the worst symptoms in the questionnaire for you? and – Do you have any other disabling symptom which is not listed on the questionnaire?
The standardized clinical assessment was carried out by neurologists who were blinded to the study objectives. The investigator, soon after consultations, subtly inquired to neurologists: – “The patient who you just saw shows wearing off?” The results obtained through WOQ-9 were compared with the responses of the physicians.
The Unified Parkinson's Disease Rating Scale (UPDRS)1717 . Goetz CG, Tilley BC, Shaftman SR, Stebbins GT, Fahn S,
Martinez-Martin P et al. Movement Disorder Society sponsored revision of the
Unified Parkinson’s Disease Rating Scale (MDS-UPDRS): scale presentation
and clinimetric testingresults. Mov Disord. 2008;23(15):2129-70.
http://dx.doi.org/10.1002/mds.22340
https://doi.org/10.1002/mds.22340...
part I to IV was applied to all patients in
“on” state. The investigator inquired how long has he/she taken
the AD and if it was near the time for the next dose. The “on”
state was attributed to the patient when he/she was in their best condition with
the effect of the medication. Their stages at Hoehn and Yahr modified scale (HY)
were also obtained. The Sum variable was performed by the sum of symptoms that
improved after the next medication dose, and used in the correlation
analysis.
Data analysis
The descriptive analysis of all variables of the study was performed. The qualitative analyses were expressed by absolute and relative frequency. Quantitative variables were expressed in terms of its values of central tendency and dispersion. In order to verify the homogeneity of variances and the adherence to the normal curve Levene test and Kolmogorov-Smirnov test were used respectively. The Spearman correlation coefficient was used to assess whether there was correlation between the presence of WO according to WOQ-9 and age, educational level, disease duration, total UPDRS and Hoehn and Yahr stage. In order to compare the questionnaire to the gold standard method we calculated the sensitivity, specificity, positive and negative predictive values. To verify the association between the qualitative variables, such as the presence of a symptom detected by the physicians and the WOQ-9, we used Fisher's exact test. The significance level was 5%1818 . Callegari-Jacques SM. Bioestatística: princípios e aplicações. Porto Alegre: Artmed; 2003.. The statistical software utilized was: SPSS 17.0 for Windows.
Results
The WOQ-9 was answered by sixty patients and their age ranged from 31 to 89 years old (mean=60.1, standard deviation=13.9). Thirty five patients were male (58.3%) and twenty-five were female (41.7%). The duration of the disease varied from 3 to 16 years (mean=9.9, standard deviation=5.5). The educational level ranged from 2 to 19 studied years (mean=8, standard deviation=4.45).
Homogeneity between the answer given by the physician and the detection of WO by WOQ-9 was observed (Fisher's exact test, p<0.05). The congruence for the detection of WO by the physicians and WOQ-9 was obtained in 54.5% of the cases. In 45.6% of the cases WO was identified only by the WOQ-9, as shown in the Table 1.
With regard to the questionnaire, it showed a sensitivity of 100%, specificity of 10.3%, PPV of 54.4%, and NPV of 100% (confidence interval of 95%). Receiver Operator Curve (ROC) curves were plotted to analyze the results of sensitivity and specificity. The curves demonstrated statistical significance for the detection of WO by WOQ-9 when analyzed individually, but not for the detection of WO by neurological evaluation (Figure 1).
Sensitivity and specificity of the evaluation by physicians and Nine Items Questionnaire for WO (WOQ-9) for detect wearing-off (WO).
The most and least frequent symptoms were Any Slowness in Movement (93.3%) and Pain/Aching (65.0%), respectively. The frequency of each WOQ-9 symptom is shown in Figure 2.
The symptoms mostly appointed as “the worst” by the patients were: Tremor (25.6%) and Any Stiffness (24.4%), as shown in Figure 3. When questioned if there were any other disabling symptoms but was not listed on the WOQ-9, the patients diverged considerably but they reported mostly Gait Disorders (7.7%) and Dyskinesias (6.2%).
The total UPDRS score ranged from 8 to 110 (mean=63.2, standard deviation=25.5). Regarding to HY, no patient was in stage 1, four were in stage 1.5 (6.7%), ten in stage 2 (16.7%), eleven in stage 2.5 (18.3%), twenty-five in stage 3 (41.7%) and ten in stage 4 (16.7%).
The Spearman correlation is presented in Table 2. It is noticed that there are direct correlation between: age vs. duration of disease, age vs. UPDRS total score, age vs. HY stages, educational level vs. Sum, disease duration vs. UPDRS total score, disease duration vs. HY stages, and UPDRS total score vs. HY stages. It is also observed that there was indirect or inversely proportional correlation between: educational level vs. duration of disease, educational level vs. UPDRS total score, UPDRS total score vs. Sum, and between Sum vs. HY stages.
Discussion
The original study that validated the WOQ-9 questionnaire showed high sensitivity and
low specificity to detect WO when compared with the clinical evaluation by
neurologists1414 . Stacy MA, Murphy JM, Greeley DR, Stewart RM, Murck H, Meng X. The
sensitivity and specificity of the 9-item Wearing-off Questionnaire.
Parkinsonism Relat Disord. 2008;14(3):205-12.
http://dx.doi.org/10.1016/j.parkreldis.2007.07.013
https://doi.org/10.1016/j.parkreldis.200...
,1919 . Stacy M, Murck H, Meng X. COMPASS-1: A validation study of the
9-question, wearing off questionnaire (WOQ-9). Mov Disord.
2006;21(Suppl):S590.,2020 . Stacy M. The wearing-off phenomenon and the use of questionnaires
to facilitate its recognition in Parkinson’s disease. J Neural Transm.
2010;117(7):837-46. http://dx.doi.org/10.1007/s00702-010-0424-5
https://doi.org/10.1007/s00702-010-0424-...
. The higher the sensitivity the higher is the ability of
WOQ-9 to detect WO, which also occurred in our assessed sample. The NPV in our study
was high, which implies that the questionnaire is accurate to identify those without
WO. On the other hand, the PPV was low indicating that not all WO identified by this
instrument actually existed, therefore, it does not qualify the questionnaire as a
method to diagnose WO, but rather as one screening method. As a result, this study
indicate that our WOQ-9 version is a convenient screening tool to aid physicians to
detect WO in PD patients.
In order to increase the identification of motor fluctuations, marked by the
predictability and improvement after the intake of the next dose of medication,
questionnaires including MS and NMS have been developed. The first structured
questionnaire to facilitate WO identification was originated from a literature
review conducted by ten movement disorders experts1111 . Stacy M, Bowron A, Guttman M, Hauser R, Hughes K, Larsen JP et al.
Identification of motor and nonmotor wearing-off in Parkinson’s disease:
comparison of a patient questionnaire versus a clinician assessment. Mov Disord.
2005;20(6):726-33. http://dx.doi.org/10.1002/mds.20383
https://doi.org/10.1002/mds.20383...
.
They met to conceive a prototype patient questionnaire, specifically designed to
prove the hypothesis that the sensitivity to detect signs and symptoms of WO by
means of evaluation by specialists could be increased using additional methods such
as a questionnaire. This questionnaire included 32 symptoms (WOQ-32), seventeen MS
and fifteen NMS. In the original study idealized by Stacy and colleagues1111 . Stacy M, Bowron A, Guttman M, Hauser R, Hughes K, Larsen JP et al.
Identification of motor and nonmotor wearing-off in Parkinson’s disease:
comparison of a patient questionnaire versus a clinician assessment. Mov Disord.
2005;20(6):726-33. http://dx.doi.org/10.1002/mds.20383
https://doi.org/10.1002/mds.20383...
, WOQ-32 was answered by 300
patients independently, after their routine consultations. They compared the results
of the WOQ-32 with those obtained by the standardized clinician assessment and
WOQ-32 revealed a sensitivity of 57.1% to identify WO.
Considering that WOQ-32 was not designed for routinely use, another questionnaire was
developed, based on the WOQ-32 and under rigorous statistic methods. Its final
composition included nineteen items, 9 MS and 10 NMS1212 . Stacy M, Hauser R. Development of a patient questionnaire to
facilitate recognition of motor and non-motor wearing-off in Parkinson’s
disease. J Neural Transm. 2007;114(2):211-7.
http://dx.doi.org/10.1007/s00702-006-0554-y
https://doi.org/10.1007/s00702-006-0554-...
. Statistical analysis was made out of the 32 symptoms
individually, 13 of which symptoms were selected due to its high positive predictive
value, 2 symptoms were selected for its prominence among those cited as disabling.
The logarithmic regression analysis of the disabling symptoms added 4 more symptoms,
resulting in the WOQ-19. The WOQ-19 has the same sensitivity of the WOQ-321212 . Stacy M, Hauser R. Development of a patient questionnaire to
facilitate recognition of motor and non-motor wearing-off in Parkinson’s
disease. J Neural Transm. 2007;114(2):211-7.
http://dx.doi.org/10.1007/s00702-006-0554-y
https://doi.org/10.1007/s00702-006-0554-...
.
Finally, a questionnaire with nine symptoms (WOQ-9) was designed to facilitate the
patients to answer it, while waiting for their routine consultations1313 . Stacy M, Hauser R, Oertel W, Schapira A, Sethi K, Stocchi F et al.
End-of-dose Wearing Off in Parkinson disease: a 9-question survey assessment.
Clin Neuropharmacol. 2006;29(6):312-21.
http://dx.doi.org/10.1097/01.wnf.0000232277.68501.08
https://doi.org/10.1097/01.wnf.000023227...
,1414 . Stacy MA, Murphy JM, Greeley DR, Stewart RM, Murck H, Meng X. The
sensitivity and specificity of the 9-item Wearing-off Questionnaire.
Parkinsonism Relat Disord. 2008;14(3):205-12.
http://dx.doi.org/10.1016/j.parkreldis.2007.07.013
https://doi.org/10.1016/j.parkreldis.200...
. The nine items of WOQ-9 were obtained by means
of a retrospective statistical analysis of the WOQ-32 symptoms more frequent in the
patients with WO followed by a canonical discriminant analysis to identify the
symptoms that were better predictive to identify WO in the patients with WO and not
detected by doctor’s assessment from original WOQ-32 study1313 . Stacy M, Hauser R, Oertel W, Schapira A, Sethi K, Stocchi F et al.
End-of-dose Wearing Off in Parkinson disease: a 9-question survey assessment.
Clin Neuropharmacol. 2006;29(6):312-21.
http://dx.doi.org/10.1097/01.wnf.0000232277.68501.08
https://doi.org/10.1097/01.wnf.000023227...
. The sensitivity of WOQ-9 was
96.2% and specificity 40.9%, proving its usefulness as a screening method1414 . Stacy MA, Murphy JM, Greeley DR, Stewart RM, Murck H, Meng X. The
sensitivity and specificity of the 9-item Wearing-off Questionnaire.
Parkinsonism Relat Disord. 2008;14(3):205-12.
http://dx.doi.org/10.1016/j.parkreldis.2007.07.013
https://doi.org/10.1016/j.parkreldis.200...
. As for the frequency of the
WOQ-9 symptoms, either individually or collectively, the NMS were always neglected.
This finding was also noticed in other studies, and draws attention to the
importance of the presence of the four NMS in WOQ-9, although less referred but of
great clinical significance. This is in agreement with the analysis of Stacy et
al.1414 . Stacy MA, Murphy JM, Greeley DR, Stewart RM, Murck H, Meng X. The
sensitivity and specificity of the 9-item Wearing-off Questionnaire.
Parkinsonism Relat Disord. 2008;14(3):205-12.
http://dx.doi.org/10.1016/j.parkreldis.2007.07.013
https://doi.org/10.1016/j.parkreldis.200...
, who found that the
sensitivity and specificity of WOQ-9 are equivalent to a scale that only uses five
motor items. Furthermore, even not listed in the questionnaire, the NMS are always
self-reported by the patients, which reflect that these symptoms are substantially
uncomfortable for them2121 . Barbosa ER. Non-motor symptoms in Parkinson's disease. Arq
Neuropsiquiatr. 2013;71(4):203-4.
http://dx.doi.org/10.1590/0004-282x20130001
https://doi.org/10.1590/0004-282x2013000...
. On the
other hand, the MS are most easily detected and cause a greater impact on PD
patients’ quality of life. A multicenter study applied a questionnaire of 18
symptoms (9 MS and 9 NMS) in one hundred and sixty patients, of whom 86% presented
WO, and none NMS occurred isolated, but always associated with at least one MS2222 . Santens P, Noordhout AM. Detection of motor and non-motor symptoms
of end-of dose wearing off in Parkinson's disease using a dedicated
questionnaire: a Belgian multicenter survey. Acta Neurol Belgica.
2006;106(3):137-41..
We chose to compare the UPDRS Total score with the WOQ-9 sensitivity, despite of many
studies that have compared the UPDRS Question 36 (presence of predictable
off periods) with the Wearing-Off Questionnaires
sensitivity1111 . Stacy M, Bowron A, Guttman M, Hauser R, Hughes K, Larsen JP et al.
Identification of motor and nonmotor wearing-off in Parkinson’s disease:
comparison of a patient questionnaire versus a clinician assessment. Mov Disord.
2005;20(6):726-33. http://dx.doi.org/10.1002/mds.20383
https://doi.org/10.1002/mds.20383...
,2323 . Martinez-Martin P, Tolosa E, Hernandez B, Badia X. Validation of
the “QUICK” questionnaire - a tool for diagnosis of
“wearing-off” in patients with Parkinson's disease. Mov
Disord. 2008;23(6):830-6. http://dx.doi.org/10.1002/mds.21944
https://doi.org/10.1002/mds.21944...
. Recently, a cross-sectional
analysis has assessed the clinically important differences between the subscales
from UPDRS, as well as the UPDRS motor score and the UPDRS total score. This study
revealed better sensitivity of UPDRS total score to detect NMS2424 . Shulman LM, Gruber-Baldini AL, Anderson KE, Fishman PS, Reich SG,
Weiner WJ. The clinically important difference on the unified Parkinson's
disease rating scale. Arch Neurol. 2010;67(1):64-70.
http://dx.doi.org/10.1001/archneurol.2009.295
https://doi.org/10.1001/archneurol.2009....
.
Finally, the educational level required to answer the questionnaire restricted the
sample size. However, enabled that WOQ-9 could be used as it was conceived in its
original design. The WOQ-9 was filled out by the patients themselves as they waited
for their routine consultations. Another study was conducted in the same institution
in order to analyze the applicability of WOQ-19. Although, its methodology allowed
achieving a larger sample size, since the questionnaire was read for the patients
and the answers registered by the researcher2525 . Melo LM, Chien HF, Barbosa ER. Identification of wearing-off
manifestations (reduction of levodopa effect) in Parkinson's disease using
specific questionnaire and comparison of the results with routine ambulatory
evaluations. Arq Neuropsiquiatr. 2010;68(4):506-10.
http://dx.doi.org/10.1590/s0004-282x2010000400007
https://doi.org/10.1590/s0004-282x201000...
. The average schooling of eight years is similar to
other studies conducted in developed countries2323 . Martinez-Martin P, Tolosa E, Hernandez B, Badia X. Validation of
the “QUICK” questionnaire - a tool for diagnosis of
“wearing-off” in patients with Parkinson's disease. Mov
Disord. 2008;23(6):830-6. http://dx.doi.org/10.1002/mds.21944
https://doi.org/10.1002/mds.21944...
,2626 . Chan A, Cheung YF, Yeung MA, Yeung J, Chung TH, Tsang KL et al. A
validation study of the Chinese wearing off questionnaire 9-symptom for
Parkinson's disease. Clin Neurol Neurosurg. 2011;11397):538-40.
http://dx.doi.org/10.1016/j.clineuro.2011.03.007
https://doi.org/10.1016/j.clineuro.2011....
.
In conclusion, the recognition of WO, which may be disabling for some patients, allows its prompt treatment and may delay its progression. Although we used a not validated Brazilian Portuguese translation of WOQ-9, it is a convenient screening tool to aid physicians to detect WO in PD patients, and it is a quick and easy self-administered questionnaire.
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» https://doi.org/10.1002/mds.21944 -
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» https://doi.org/10.1016/j.clineuro.2011.03.007
Publication Dates
-
Publication in this collection
Nov 2014
History
-
Received
15 Apr 2014 -
Reviewed
24 July 2014 -
Accepted
12 Aug 2014